Patient name:

Date of birth:
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Screening Questionnaire for Live Attenuated Intranasal Influenza Vaccination

For adult patients as well as parents of children to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child live attenuated intranasal influenza vaccine (FluMist) today. If you answer yes to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, Dont please ask your healthcare provider to explain it. Yes No Know 1. Is the person to be vaccinated sick today? 2. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine? 3. Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine (FluMist) in the past? 4. Is the person to be vaccinated younger than age 2 years or older than age 49 years? 5. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder? 6. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, has a healthcare provider ever told you that he or she had wheezing or asthma? 7. Does the person to be vaccinated have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs? 8. Is the person to be vaccinated receiving antiviral medications?

9. Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy? 10. Is the person to be vaccinated pregnant or could she become pregnant within the next month? 11. Has the person to be vaccinated ever had Guillain-Barr syndrome? 12. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)? 13. Has the person to be vaccinated received any other vaccinations in the past 4 weeks?

Form completed by: __________________________________________________ Date:_________________________ Form reviewed by: ___________________________________________________ Date: ________________________
Technical content reviewed by the Centers for Disease Control and Prevention, August 2011.

www.immunize.org/catg.d/p4067.pdf Item #P4067 (8/11)

Immunization Action Coalition 1573 Selby Ave. St. Paul, MN 55104 (651) 647-9009 www.immunize.org www.vaccineinformation.org

Information for Health Professionals about the Screening Questionnaire for Intranasal Influenza Vaccination
Are you interested in knowing why we included a certain question on the Screening Questionnaire? If so, read the information below. If you want to find out even more, consult the sources listed at the bottom of this page.
1. Is the person to be vaccinated sick today? There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events. Persons with an acute febrile illness usually should not be vaccinated until their symptoms have improved. Minor illnesses with or without fever do not contraindicate use of influenza vaccine. Do not withhold vaccination if a person is taking antibiotics. 2. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine? A history of anaphylactic or non-anaphylactic reactionsuch as hives, wheezing, or difficulty breathing, or circulatory collapse or shock (not fainting)after eating eggs or receiving any component of the intranasal live attenuated influenza vaccine (LAIV, tradename FluMist) is usually a contraindication for further doses. Check the package insert (at www. immunize.org/packageinserts) for a list of the vaccine components (i.e., excipients and culture media) used in the production of the vaccine, or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/ excipient-table-2.pdf. 3. Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine (FluMist) in the past? Patients reporting a serious reaction to a previous dose of LAIV should be asked to describe their symptoms. Immediatepresumably allergic reactions are usually a contraindication to further vaccination with LAIV. 4. Is the person to be vaccinated younger than age 2 years or older than age 49 years? LAIV is not licensed for use in persons younger than age 2 years or older than age 49 years. 5. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder? Persons with any of these health conditions should not be given the LAIV. Instead, they should be vaccinated with the inactivated injectable influenza vaccine. 6. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, has a healthcare provider ever told you that he or she had wheezing or asthma? LAIV is not recommended for a child this age if their parent or guardian answers yes to this question or if the child has a history of asthma or recurrent wheezing. Instead, they should be given the inactivated injectable influenza vaccine. 7. Does the person to be vaccinated have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as highdose steroids, or cancer treatment with radiation or drugs? Persons with weakened immune systems should not be given the LAIV. Instead, they should be given the inactivated injectable influenza vaccine. 8. Is the person to be vaccinated receiving antiviral medications? Receipt of certain influenza antivirals (e.g., amantadine, rimantadine, zanamivir, oseltamivir) could reduce LAIV vaccine efficacy; therefore, providers may want to defer vaccination with LAIV in persons who took these antivirals within the previous 48 hours and to advise avoiding use of these antivirals for 14 days after vaccination, if feasible. 9. Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy? Because of the theoretical risk of Reyes syndrome, children and teens on aspirin therapy should not be given LAIV. Instead they should be vaccinated with the inactivated injectable influenza vaccine. 10. Is the person to be vaccinated pregnant or could she become pregnant within the next month? Pregnant women or women planning to become pregnant within a month should not be given LAIV. All pregnant women should, however, be vaccinated with the inactivated injectable influenza vaccine. 11. Has the person to be vaccinated ever had Guillain-Barr syndrome? It is prudent to avoid vaccinating persons who are not at high risk for severe influenza complications but who are known to have developed Guillain-Barr syndrome (GBS) within 6 weeks after receiving a previous influenza vaccination. As an alternative, physicians might consider using influenza antiviral chemoprophylaxis for these persons. Although data are limited, the established benefits of influenza vaccination for the majority of persons who have a history of GBS, and who are at high risk for severe complications from influenza, justify yearly vaccination. 12. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in a protective isolation (e.g., an isolation room of a bone marrow transplant unit)? Inactivated injectable influenza vaccine is preferred for persons who anticipate close contact with severely immunosuppressed persons during periods in which the immunosuppressed person requires care in protective isolation (e.g., in a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes). Either the inactivated injectable influenza vaccine or LAIV may be used in persons who have close contact with persons having lesser degrees of immunosuppression. 13. Has the person to be vaccinated received any other vaccinations in the past 4 weeks? Persons who were given an injectable live virus vaccine (e.g., MMR, MMRV, varicella, yellow fever) in the past 4 weeks should wait 28 days before receiving LAIV. There is no reason to defer giving LAIV if persons were vaccinated with an inactivated vaccine or if they have recently re-

ceived blood or other antibody-containing blood products (e.g., IG).

Sources: 1. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases, WL Atkinson et al., editors, at www.cdc.gov/vaccines/pubs/pinkbook. 2. CDC. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) at www.cdc.gov/ vaccines/pubs/ACIP-list.htm. 3. CDC. Prevention and Control of InfluenzaRecommendations of ACIP at www.cdc.gov/flu/professionals/vaccination.

Immunization Action Coalition Item #P4067 p. 2